In patients with cerebral metastases and well controlled systemic disease, the former becomes a more significant determinant of survival. It is within this subgroup of patients that aggressive treatment, including surgery, is considered. Resection of single brain metastases was initially advocated for patients with good prognoses because of the low rates of long-term tumor control (40% at 1 year) with conventional WBRT . Prospective randomized trials have firmly established the superiority of surgical resection followed by WBRT to WBRT alone for a single cerebral metastasis . The median duration of survival is 10-14 months rather than 4-6 months. As noted above, although direct comparisons of surgery and radiosurgery for a single metastasis have not yet been completed, radiosurgery is often an acceptable alternative to craniotomy. Also, a surgically inaccessible location, multiple brain metastases or extensive systemic disease usually contraindicate resection. An exception is the need to resect a tumor from a location, such as the posterior fossa, in which it is immediately life threatening, even if the patient has multiple metastases and significant systemic disease.
The utility of surgery for multiple cerebral metastases is controversial. Modern surgical series show that early post-operative mortality and morbidity following resection of multiple metastases is comparable to those following resection of a single metastasis. One study found a significantly shorter duration of survival (5 vs 12 months) of patients who had multiple metastases resected compared to those undergoing surgery for a single metastasis. However, gross resection of all tumors was not achieved in the majority of patients with multiple lesions. Another study reported a median
TUMORS: CEREBRAL METASTASES AND LYMPHOMA
duration of survival of 14 months for patients with two or three metastases that were totally resected - a result similar to that achieved for patients with single metastases. These studies support surgical removal of one to three metastases, particularly those too large to be treated by radiosurgery .
Historically, most patients have received WBRT post-operatively - even those whose tumors were totally removed. Currently, however, many consider WBRT to be relatively contraindicated by its chronic sequelae in patients expected to live longer than 6 months. Although some studies have found that postoperative WBRT lengthens median survival, several others have found no significant difference between patients treated with surgical resection alone and those receiving resection and post-operative WBRT. Post-operative WBRT, however, did yield other benefits: improved control of local tumor, decreased risk of distant tumor, increased time to neurological recurrence and decrease in the percentage of patients dying of neurologic disease . Postoperative radiosurgery, in addition to WBRT, may be indicated in cases of incomplete removal of a metastasis. As an alternative to postoperative WBRT, it is likely to improve control of local tumor but not affect the incidence of distant metastases.
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